Provider Demographics
NPI:1154458537
Name:BRAY, BRUCE EDWARD
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWARD
Last Name:BRAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 ASH ST
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-1234
Mailing Address - Country:US
Mailing Address - Phone:715-635-2151
Mailing Address - Fax:
Practice Address - Street 1:707 ASH ST
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-1234
Practice Address - Country:US
Practice Address - Phone:715-635-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36181-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN426517300Medicaid
MN426517300Medicaid